The template
Therapy Progress Note Client: [identifier your setting uses] Date of service: [date] Start and end time: [00:00 to 00:00] Session type: [individual / couple / family / group; in person or telehealth] Telehealth (optional): [client's location this session; video or audio only] Who attended: [client; anyone else present and their relationship to the client] Service code: [if you bill] Clinician: [name, credentials] Diagnosis (optional): [from your treatment plan, if applicable] Treatment-plan goal(s) addressed: [goal number and wording] Client report: [concerns, changes since last session, homework; in their words where useful] Observations: [appearance, affect, speech, thought process, engagement] Measures: [name, score, date; last score for comparison] Interventions: [what you did, named specifically] Client response: [how the client responded to today's interventions] Progress toward goals: [where the client stands on each goal addressed, with evidence] Risk: [what you asked about thoughts of suicide, self-harm or harm to others; what the client reported; your risk judgment and reasoning; safety-plan updates] Plan: [next session focus, homework, referrals or coordination] Next appointment: [date and frequency] Signature, credentials, date: [ ] Supervisor co-signature (if required): [ ]
What goes in each part
The basics. Date, start and end time, session type and who attended. For telehealth, the client's location during the session and whether it was video or audio only. Your payer may also expect a service code and a diagnosis from the treatment plan.
Client report and observations. What the client said, in their own words where it helps, and what you saw. Keep the two apart so a reader can tell report from observation. Describe behavior rather than labels: "gave short answers when asked about work" rather than "guarded".
Measures. Name the measure, the score and the date, and give the last score so change is visible. Spell out the range the first time you use a measure.
Interventions and response. Name what you did ("behavioral activation: scheduled two activities", not "provided support") and how the client responded during the session.
Progress toward goals. Name the treatment-plan goal and where the client stands against it, with a count, score or rating.
Risk. Record what you asked and what the client said, including no. If the client reports thoughts of suicide, record plan, intent, preparatory behavior, past attempts, access to means (firearms, stockpiled medication), risk factors, protective factors and your judgment of risk with its reasoning, plus the safety plan, which names crisis resources such as the 988 Suicide and Crisis Lifeline. If the client reports thoughts of harming someone else, record toward whom, plan, intent and means, follow your setting's protocol and check your state's duty-to-warn or duty-to-protect law.
Plan. The next session's focus, homework, referrals or coordination, and the next appointment.
Two filled examples
All examples on this page are fictional composites. They do not describe real clients.
1. Adult in their 60s, grief, in person, 50 minutes. Goal 2: return to two valued activities a week.
Client report: Went to choir once this week, the first time since their spouse died 5 months ago; skipped the walking group. Said, "I felt guilty enjoying it, then glad I went." Sleeping about 6 hours, up from 5. Observations: On time, neatly dressed. Tearful when speaking about their spouse, smiled when describing choir. Speech and thought process clear. Measures: Patient Health Questionnaire-9 (PHQ-9, scored 0 to 27): 11 (item 9: 0), down from 14 four weeks ago; both in the moderate range. Interventions: Reviewed the activity log. Behavioral activation: scheduled choir and one walking-group session for the coming week. Psychoeducation on mixed feelings in grief; explored the guilt about enjoying choir. Client response: Engaged. Named one barrier to the walking group (the drive passes the hospital) and chose a different route. Progress toward goals: Goal 2 partly met: 1 of 2 planned activities this week (0 at intake). Small improvement on the PHQ-9. Risk: Asked about thoughts of suicide, self-harm or harm to others; client denies all. PHQ-9 item 9: 0. Judged low risk: no ideation reported; recent bereavement noted as a risk factor; protective factors include a daughter nearby, weekly choir and engagement in treatment. Plan: Choir and one walking-group session; note mood after each. Continue grief-focused work on guilt. Next appointment: one week.
2. Adult in their 20s, depression with passive thoughts of suicide, telehealth, 50 minutes. Goal 1: re-engage with daily routine and people (PHQ-9 below 10 by week 12).
Telehealth: client at home, at the address on file; video. Location confirmed at the start of session. Client report: Breakup 10 days ago. Stayed in bed most of the weekend and missed one workday. Twice this week had the thought that "it would be easier not to wake up." Observations: Flat affect, slowed speech, good eye contact. Answered all questions. Thought process organized. Measures: PHQ-9: 17 (item 9: 1), up from 13 two weeks ago; now in the moderately severe range. Interventions: Direct suicide risk assessment. Safety planning: wrote a safety plan with the client (warning signs, coping steps, people and places for distraction, people to ask for help, professional contacts including the 988 Suicide and Crisis Lifeline, and steps to make the home safer). Behavioral activation: planned two activities for the next three days. Client response: Engaged in writing the safety plan and named their sister as the first person to call. Agreed to give leftover prescription pain medication from a past surgery to their roommate to keep. Progress toward goals: Goal 1 setback since the breakup: PHQ-9 up 4 points; 1 of 3 planned activities done this week. Risk: Passive thoughts of suicide twice this week. Denies plan, intent, preparatory behavior and past attempts. Denies self-harm and thoughts of harming others. No firearms at home and no access to them. Has leftover prescription pain medication at home; agreed to give it to their roommate to keep. Risk factors: recent breakup, worsening depression, withdrawal from friends. Protective factors: close sister, engaged in treatment, new job starting next month, names reasons for living. Judged low acute risk: passive ideation without plan, intent or past attempts; no firearm access and a plan to remove the medication; protective factors present. Risk is raised since the last session, so session frequency is increased. Plan: Client to text their sister tonight and keep the safety plan on their phone. Two planned activities before next session. Confirm at next session that the roommate has the medication. Repeat PHQ-9 and ask about suicidal thoughts at each session. Next appointment: in 3 days, then weekly.
Common mistakes
- Missing basics. A note without the date, start and end time, session type or who attended is hard to rely on later. Fill them in every time.
- No interventions recorded. A note that only describes the client's week does not show what you did. Name the intervention.
- No link to the treatment plan. Name the goal and how the client is doing against it.
- A risk judgment with no reasoning. "Low risk" on its own does not show how you got there. Record what the judgment rests on.
- Copying last week's note forward. Each note should describe this session.
- Too much detail. Record what is clinically relevant. Long verbatim accounts add length for the next reader and expose more of the client if records are shared.
Using a structured format instead
The same parts fit into the structured formats. SOAP splits the client's report from your observations, DAP combines them, and BIRP and GIRP organize the note around your intervention and the client's response. See the SOAP, DAP, BIRP and GIRP templates, or one session written three ways in the therapy progress note examples.
FAQ
What should a therapy progress note include?
The date, start and end time, session type and who attended; what the client reported; what you observed; the interventions you used and the client's response; progress toward treatment-plan goals; a risk check; and the plan. Your licensing board, agency or payer may require more, such as a diagnosis or a statement of why treatment continues.
Is there a PDF version of this progress note template?
The template is plain text so it pastes cleanly into an EHR text box. If you keep paper records, paste it into a document, adjust the fields to your setting and save or print it as a PDF.
What is the difference between a progress note and psychotherapy notes?
A progress note is the official record of treatment. Psychotherapy notes, as HIPAA defines them, are a therapist's separate notes documenting or analyzing the conversation in session, kept apart from the record and given extra privacy protection. Session times, modality, test results, diagnosis, treatment plan, symptoms and progress belong in the progress note, not in psychotherapy notes.
How soon after a session should I write the progress note?
Your setting or payer may set a deadline. Without one, writing the note the same day, while the session is fresh, helps you record it accurately.
How long should a therapy progress note be?
Long enough that another clinician could understand the session and continue the work. For a routine session, that can be a few lines per part.
This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.